Care Coordination

A model of care for beneficiaries with myriad health and social needs. Typically, a coordination team made up of behavioral, acute, primary medical and LTSS specialists work together with individual beneficiaries to ensure their needs are met while preventing medical errors or duplication of services. Can also be referred to as a medical home. While there is no standard definition, most care coordination programs target high-risk beneficiaries to improve coordination of both medical and social supports provided by different organizations and providers.6 For example, care coordination may assist beneficiaries with transportation needs, engage them in writing a self-directed and patient-centered plan of care, navigate the boundaries of systems of care on their behalf, or broker medical and social services. Managed care organizations’ (MCOs) approaches to care coordination programs vary, ranging from a centralized team model comprised of nurses and social workers located in the MCO’s central offices, to a provider-based model that assigns staff to support specific provider groups. In contrast to care coordination, case management services tend to apply a medical model that focuses primarily on the beneficiary’s health care. Another distinction is that care coordination programs often facilitate the delivery of both covered and non-covered Medicaid services.